Week 5: Comprehensive Psychiatric Evaluation And Patient Case.

Comprehensive Psychiatric Evaluation And Patient Case Presentation

Stress and pressure that individuals face from circumstances such as their jobs or

homes can have significant effects on their mental health (English et al., 2018). This

pressure may become overwhelming and increase the risk of an individual developing a

mental health problem (English et al., 2018). The pressure can result in other effects such

as sleep disturbances or difficulty in eating which are also indications of underlying mental

health problems (English et al., 2018). The purpose of this paper is to conduct a

comprehensive psychiatric evaluation based on a patient under similar circumstances.

The paper will discuss objective, subjective, assessment, and reflection notes data.

CC (chief complaint): “I have lots of pressure at home and at work”.

HPI: The patient is a 41-year- old Hispanic female presenting for initial evaluation with

complaints of having lots of pressure at home and at work. The patient explains that she

does not feel very good and even though she tries to concentrate at work, she never gets

enough sleep and barely eats much.

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The patient explained that she has mood

fluctuations with her mood going up and down causing her to sometimes cry herself to

sleep. She explains that this is an issue that she has struggled with for some time now but

does not give the specific duration. The patient is currently taking Mirtazapine 15 MG oral

tablet daily at bedtime. She explains that she does not smoke nor does she abuse any

other substance and her past medical history includes mood issues. She is married

although her husband still resides in Mexico and she currently lives in the state of

Maryland. There is no report of a history of trauma and she denies any suicidal or

Tabitha Perrigo DNP PMHNP

At the top of your HPI even though this is an initial evaluation with you obviously this patient has a previous diagnosis in history you would want to begin your HPI with patient presents today for an initial evaluation with this provider but carries a diagnosis of depression that she started medication for one year ago two years ago however long that he is re-organize your HPI and write it in chronological order. When the symptoms first began if there’s a diagnosis if there’s medication what symptoms are currently going on what order did they present how long have they been present

Tabitha Perrigo DNP PMHNP

Including the beginning at the top of the HPI if she’s currently taking medication for how long and who prescribed it and what is it prescribed for

Tabitha Perrigo DNP PMHNP

Follow up with a question if you had to estimate how long is this been going on has it been going on at least a month two months specifying the duration is important to justifying your diagnosis

Tabitha Perrigo DNP PMHNP

Are the mood fluctuations over the course of a single day does she have an up mood for a week and then a down mood for a week these are questions you need to clarify on an HPI because this indicates whether the presence of depression personality disorders versus a bipolar disorder.

Tabitha Perrigo DNP PMHNP

The patient reports decrease in appetite lack of sleep and poor concentration. Keep in mind that you want to present the symptoms and his few of words as possible there is more value in being clear and concise than wordy.

Tabitha Perrigo DNP PMHNP

Good clear yet brief chief complaint good job

homicidal ideations or plans. The patient does not have visual auditory hallucinations,

paranoia, or delusions.

Past Psychiatric History:

 General Statement: the patient has been previously diagnosed with mood issues.

 Caregivers (if applicable): The patient’s children.

 Hospitalizations: the patient has no history of hospitalization

 Medication trials the patient is currently taking Mirtazapine15 MG orally at bedtime.

 Psychotherapy or Previous Psychiatric Diagnosis: the patient has a previous

psychiatric diagnosis of mood issues

Substance Current Use and History: the patient denies the use of any substance both

currently and historically.

Family Psychiatric/Substance Use History: the patient’s brother has mood problems.

No other member of the patient’s family is reported to have any disorder.

Psychosocial History: The patient is working although there is no specification of her

occupation. The patient explains that she has been working for 17 years and has

managed to foster a good relationship with her peers. She lives in the state of Maryland

and has four children aged 21, 13, and 6-year old twins. The patient raises the children

alone and reports that she is married but the husband is still in their country of origin

which is Mexico. The patient had normal birth and explains that she is heterosexual.

Tabitha Perrigo DNP PMHNP

What is her educational background did she attend school does she have a good relationship with her children a good psychosocial history can provide you with much information not only for the diagnosis but for potential therapies down the road

Tabitha Perrigo DNP PMHNP

Be sure to clearly document if there’s a family history of completed suicide or violence

Tabitha Perrigo DNP PMHNP

Who prescribed this medication when where and for watt

Tabitha Perrigo DNP PMHNP

Be specific what type of mood issues that is vague

Medical History:

 Current Medications: Mirtazapine15 MG orally at bedtime

 Allergies: there are no known drug, food, or environmental allergies for the

patient.

 Reproductive Hx: Heterosexual

ROS:

 GENERAL: Reports depressed mood, trouble sleeping and eating. Does not have

weight loss, fever, chills, weakness, or fatigue.

 HEENT: Does not have visual loss, blurred vision, double vision, or yellow sclerae.

Does not have hearing loss, sneezing, congestion, runny nose, or sore throat.

 SKIN: Does not have visible rash or itching.

 CARDIOVASCULAR: does not have chest pain, chest discomfort, or chest

pressure. Does not have palpitations or edema.

 RESPIRATORY: does not have shortness of breath, cough, or sputum.

 GASTROINTESTINAL: Has decreased appetite. Does not have vomiting, nausea,

or diarrhea.

Tabitha Perrigo DNP PMHNP

You can include hear the number of births that she’s given has she had any miscarriages were her pregnancies normal where they traumatic go further detail with your reproductive history

 GENITOURINARY: does not have burning sensation during urination; the color is

standard; has normal odor.

 NEUROLOGICAL: does not have headaches, dizziness, seizures, tremors, ataxia,

paralysis, numbness, or tingling in the extremities.

 MUSCULOSKELETAL: Does not have muscle pain, back pain, joint pain, or

stiffness.

 HEMATOLOGIC: does not have anemia, bleeding, or bleeding.

 LYMPHATICS: does not have enlarged nodes. Does not have history of

splenectomy.

 ENDOCRINOLOGIC: does not have reports of sweating, cold, or heat intolerance.

Does not have polydipsia or polyurea.

Physical exam: VITAL SIGNS

Height: 5’6”

Weight: 272 lbs.

Blood Pressure: 132/68

Temperature: 97.3

Pulse: 76

Respiratory rate: 18

O2 Saturation: 98

Pain: No pain

Tabitha Perrigo DNP PMHNP

It’s generally a good idea to include a statement such as the patient displays no acute distress

Diagnostic tests/results:

Hamilton Rating Scale for Depression

This is a diagnostic test that the care provider can use to assess whether the symptoms

presented are in correspondence to those of depression. The test is offered as a multiple

choice questionnaire and it rates the presence and severity of the depression of the

patient.

Insomnia-Interview questions

Since there is no specific test for diagnosing insomnia, a care provider can perform a

physical exam together with interview questions about specific sleep problems and

symptoms to identify whether the symptoms presented by the patient point to insomnia as

the diagnosis.

Assessment

Mental Status Examination:

The patient is a 41-year-old Hispanic female who looks her stated age. She is

calm and cooperative with the examiner and has good eye contact. She has the ability of

verbally responding to questions appropriately with intact memories. She is well dressed

and appropriate to the occasion. There is no evidence of any abnormal motor activity.

The speech of the patient is clear, coherent, and normal in volume and tone. The mood is

euthymic and affect is congruent with mood. She has coherent, goal directed, and linear

thought process. There is no evidence of looseness of association or flight of ideas. The

patient denies auditory or visual hallucinations. There is no evidence of any delusional

thinking. The patient denies having suicidal or homicidal ideations. Judgment and

Tabitha Perrigo DNP PMHNP

Week 5: Comprehensive Psychiatric Evaluation And Patient Case.

cognition are good and her insight is very good as well. Patient’s recent and remote

memory is intact.

Differential Diagnoses:

1. Major Depressive Disorder

Based on the symptoms of the patient, this appears to be the most likely primary

diagnosis. DSM 5 criteria describes Major Depressive Disorder as persistent feelings of

sadness with symptoms including depressed mood most of the day nearly every day, a

decrease in appetite, and sleep disturbances (Hasin et al., 2018). These symptoms are

present in the patient because she states feeling sad and sometimes crying herself to

sleep, failing to get enough sleep, and having problems eating. Additionally, the patient

explains that she has a lot of pressure at home and at work. Research has reported that

when an individual has a lot of pressure whether at home or at work and they do not cope

well with this pressure, the risk of developing depression is increased (Balcombe & De

Leo, 2021). This is likely to be the case of the patient. Also, it is reported by research that

if a family member has a mood disorder then this highly increases the risk of an individual

developing depression (Hasin et al., 2018). In the patient’s case, her brother has mood

problems which increases her risk for developing depression.

2. Insomnia

Insomnia is a possible diagnosis for this patient because the patient’s symptoms

correspond with those of insomnia. Insomnia is described by DSM 5 as the inability to get

satisfactory quantity or quality of sleep (Riemann et al., 2020). This is evident in the case

of the patient because she states that she does not sleep good at all. Also, it is reported

by research that being under pressure can impact the mental or physical health of an

individual hence disrupting sleep (Riemann et al., 2020). This goes ahead to cause

temporary or chronic insomnia depending on their severity of the pressure or stress

(Riemann et al., 2020). This is true in the case of the patient because she admits to facing

a lot of pressure from her home and work. However, this diagnosis is ruled out because

insomnia can only be considered a primary diagnosis when the symptoms are not better

explained by other mental disorders yet in this case, sleeping problems and decreased

appetite are mainly associated with depression (Zimmerman et al., 2019).

3. Generalized Anxiety Disorder

This is considered a likely diagnosis for this patient because of how her symptoms

resemble those of the GAD disorder. According to DSM 5, sleep difficulties maybe an

indication of this condition because they may be caused by pressure and stress from job

responsibilities or performance, family issues, financial matters, and other life

circumstances (Saulnier, et al., 2021). This is true for the patient because she admits to

being under a lot of pressure at home and at work as well as not being able to sleep well.

However, the diagnosis is ruled out because there are no reports of excessive worry even

when there is no specific threat, which is the main characteristic diagnosis of this

condition (Saulnier, et al., 2021). Additionally, these symptoms can be better explained by

another medical condition which is Major Depressive Disorder.

Plan of Care

The plan of care is aimed at maintaining stability from depression, poor appetite,

and insomnia in the course of the next 90 days. The plan includes continuing Mirtazapine

15 MG, educating the patient on medication and interactions, educating the patient on

using positive coping skills, instructing the patient to report any medication side effects,

encouraging the patient to engage in healthy lifestyle, conducting follow up of the patient

in two weeks, and asking the patient to call 911 in case of suicidal or homicidal ideations.

Reflections:

This patient case has reinforced my knowledge regarding how sleep disturbances

can be a symptom in several conditions and pressure from work or home can be a

contributing factor to the development of various mental conditions. It is, therefore,

important to consider additional symptoms before making a diagnosis. What I would do

differently is asking about more information regarding the mood issue listed in the

patient’s past medical history so that it is narrowed down to the specific mood issues as

well as the mood problems faced by the brother. An ethical consideration at this point

would be ensuring that the medication prescribed to the patient does not have side

effects which may limit the ability of the patient to perform daily tasks because she is

working and has four children to take care of all by herself.

Conclusion

The comprehensive psychiatric evaluation above has reviewed all the information

that is relevant in assessing the case of the patient and making the accurate diagnosis. It

is evident that while the patient may be showing symptoms of a certain condition, the

symptoms may be found in another condition as well. Therefore, it is important to carry

out diagnostic tests so that all the inaccurate diagnoses can be ruled and the accurate

diagnosis can be confirmed. Additionally, there is need to consider the various possible

ethical elements which can be applicable in the case. This will help to ensure that the

evaluation and treatment process of the patient is carried out in a way that abides by the

ethical guidelines and principles found in healthcare.

Tabitha Perrigo DNP PMHNP

Catherine, overall you did a good job there’s a few areas you need to work at digging in a little further but keep working

References

Balcombe, L., & De Leo, D. (2021). Digital mental health challenges and the horizon

ahead for solutions. JMIR Mental Health, 8(3).

English, D., Rendina, H. J., & Parsons, J. T. (2018). The effects of intersecting stigma: A

longitudinal examination of minority stress, mental health, and substance use

among Black, Latino, and multiracial gay and bisexual men. Psychology of

violence, 8(6), 669.

Hasin, D. S., Sarvet, A. L., Meyers, J. L., Saha, T. D., Ruan, W. J., Stohl, M., & Grant, B.

F. (2018). Epidemiology of adult DSM-5 major depressive disorder and its

specifiers in the United States. JAMA psychiatry, 75(4), 336-346.

Riemann, D., Krone, L. B., Wulff, K., & Nissen, C. (2020). Sleep, insomnia, and

depression. Neuropsychopharmacology, 45(1), 74-89.

Week 5: Comprehensive Psychiatric Evaluation And Patient Case.